|
CYTOTEC (MISOPROST 200MCG/TAB)
|
Facility
|
IP
|
$5.17
|
|
|
Service Code
|
NDC 59762500801
|
| Hospital Charge Code |
25000509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Aetna Commercial |
$3.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.03
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna Commercial |
$4.29
|
| Rate for Payer: First Health Commercial |
$4.91
|
| Rate for Payer: Humana Commercial |
$4.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.55
|
| Rate for Payer: Ohio Health Group HMO |
$3.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.60
|
| Rate for Payer: PHCS Commercial |
$4.96
|
| Rate for Payer: United Healthcare All Payer |
$4.55
|
|
|
CYTOTEC (MISOPROST 200MCG/TAB)
|
Facility
|
OP
|
$5.17
|
|
|
Service Code
|
NDC 59762500801
|
| Hospital Charge Code |
25000509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.96 |
| Rate for Payer: Aetna Commercial |
$3.98
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.03
|
| Rate for Payer: Cash Price |
$2.58
|
| Rate for Payer: Cigna Commercial |
$4.29
|
| Rate for Payer: First Health Commercial |
$4.91
|
| Rate for Payer: Humana Commercial |
$4.39
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.55
|
| Rate for Payer: Ohio Health Group HMO |
$3.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.60
|
| Rate for Payer: PHCS Commercial |
$4.96
|
| Rate for Payer: United Healthcare All Payer |
$4.55
|
|
|
CYTOVENE (GANCICLOV 500MG/10ML
|
Facility
|
OP
|
$366.27
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
25002978
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.62 |
| Max. Negotiated Rate |
$351.62 |
| Rate for Payer: Aetna Commercial |
$282.03
|
| Rate for Payer: Anthem Medicaid |
$125.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$285.69
|
| Rate for Payer: Cash Price |
$183.14
|
| Rate for Payer: Cigna Commercial |
$304.00
|
| Rate for Payer: First Health Commercial |
$347.96
|
| Rate for Payer: Humana Commercial |
$311.33
|
| Rate for Payer: Humana KY Medicaid |
$125.96
|
| Rate for Payer: Kentucky WC Medicaid |
$127.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$300.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$270.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$128.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$322.32
|
| Rate for Payer: Ohio Health Group HMO |
$274.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.54
|
| Rate for Payer: PHCS Commercial |
$351.62
|
| Rate for Payer: United Healthcare All Payer |
$322.32
|
|
|
CYTOVENE (GANCICLOV 500MG/10ML
|
Facility
|
IP
|
$366.27
|
|
|
Service Code
|
HCPCS J1570
|
| Hospital Charge Code |
25002978
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.62 |
| Max. Negotiated Rate |
$351.62 |
| Rate for Payer: Aetna Commercial |
$282.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$285.69
|
| Rate for Payer: Cash Price |
$183.14
|
| Rate for Payer: Cigna Commercial |
$304.00
|
| Rate for Payer: First Health Commercial |
$347.96
|
| Rate for Payer: Humana Commercial |
$311.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$300.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$270.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$322.32
|
| Rate for Payer: Ohio Health Group HMO |
$274.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.54
|
| Rate for Payer: PHCS Commercial |
$351.62
|
| Rate for Payer: United Healthcare All Payer |
$322.32
|
|
|
CYTOXAN(CYCLOPHOSPHA 50MG/1TAB
|
Facility
|
OP
|
$74.94
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
25002535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$71.94 |
| Rate for Payer: Aetna Commercial |
$57.70
|
| Rate for Payer: Anthem Medicaid |
$25.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.45
|
| Rate for Payer: Cash Price |
$37.47
|
| Rate for Payer: Cigna Commercial |
$62.20
|
| Rate for Payer: First Health Commercial |
$71.19
|
| Rate for Payer: Humana Commercial |
$63.70
|
| Rate for Payer: Humana KY Medicaid |
$25.77
|
| Rate for Payer: Kentucky WC Medicaid |
$26.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.95
|
| Rate for Payer: Ohio Health Group HMO |
$56.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.23
|
| Rate for Payer: PHCS Commercial |
$71.94
|
| Rate for Payer: United Healthcare All Payer |
$65.95
|
|
|
CYTOXAN(CYCLOPHOSPHA 50MG/1TAB
|
Facility
|
IP
|
$74.94
|
|
|
Service Code
|
HCPCS J8530
|
| Hospital Charge Code |
25002535
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.74 |
| Max. Negotiated Rate |
$71.94 |
| Rate for Payer: Aetna Commercial |
$57.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.45
|
| Rate for Payer: Cash Price |
$37.47
|
| Rate for Payer: Cigna Commercial |
$62.20
|
| Rate for Payer: First Health Commercial |
$71.19
|
| Rate for Payer: Humana Commercial |
$63.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.95
|
| Rate for Payer: Ohio Health Group HMO |
$56.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.23
|
| Rate for Payer: PHCS Commercial |
$71.94
|
| Rate for Payer: United Healthcare All Payer |
$65.95
|
|
|
CYTP DX EVAL FNA 1ST EA SITE
|
Professional
|
Both
|
$251.00
|
|
|
Service Code
|
HCPCS 88172
|
| Hospital Charge Code |
30001423
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$15.95 |
| Max. Negotiated Rate |
$251.00 |
| Rate for Payer: Aetna Commercial |
$80.30
|
| Rate for Payer: Anthem Medicaid |
$44.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$251.00
|
| Rate for Payer: Cash Price |
$125.50
|
| Rate for Payer: Cash Price |
$125.50
|
| Rate for Payer: Cigna Commercial |
$33.06
|
| Rate for Payer: Healthspan PPO |
$76.24
|
| Rate for Payer: Humana Medicaid |
$44.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$45.23
|
| Rate for Payer: Molina Healthcare Passport |
$44.34
|
| Rate for Payer: Multiplan PHCS |
$150.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.70
|
| Rate for Payer: UHCCP Medicaid |
$87.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.78
|
|
|
CYTP DX EVAL FNA 1ST EA SITE
|
Facility
|
IP
|
$251.00
|
|
|
Service Code
|
HCPCS 88172
|
| Hospital Charge Code |
30001423
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$32.63 |
| Max. Negotiated Rate |
$240.96 |
| Rate for Payer: Aetna Commercial |
$193.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$201.55
|
| Rate for Payer: Cash Price |
$125.50
|
| Rate for Payer: Cigna Commercial |
$208.33
|
| Rate for Payer: First Health Commercial |
$238.45
|
| Rate for Payer: Humana Commercial |
$213.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.88
|
| Rate for Payer: Ohio Health Group HMO |
$188.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.81
|
| Rate for Payer: PHCS Commercial |
$240.96
|
| Rate for Payer: United Healthcare All Payer |
$220.88
|
|
|
CYTP DX EVAL FNA 1ST EA SITE
|
Facility
|
OP
|
$251.00
|
|
|
Service Code
|
HCPCS 88172
|
| Hospital Charge Code |
30001423
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$32.63 |
| Max. Negotiated Rate |
$240.96 |
| Rate for Payer: Aetna Commercial |
$193.27
|
| Rate for Payer: Anthem Medicaid |
$86.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$147.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$201.55
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$206.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$199.40
|
| Rate for Payer: Cash Price |
$125.50
|
| Rate for Payer: Cash Price |
$125.50
|
| Rate for Payer: Cigna Commercial |
$208.33
|
| Rate for Payer: First Health Commercial |
$238.45
|
| Rate for Payer: Humana Commercial |
$213.35
|
| Rate for Payer: Humana KY Medicaid |
$86.32
|
| Rate for Payer: Humana Medicare Advantage |
$147.70
|
| Rate for Payer: Kentucky WC Medicaid |
$87.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$205.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$185.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$88.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$220.88
|
| Rate for Payer: Ohio Health Group HMO |
$188.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.81
|
| Rate for Payer: PHCS Commercial |
$240.96
|
| Rate for Payer: United Healthcare All Payer |
$220.88
|
|
|
D5%-0.2% Sod Chlor 1000mL
|
Facility
|
IP
|
$95.21
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004489
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$91.40 |
| Rate for Payer: Aetna Commercial |
$73.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.26
|
| Rate for Payer: Cash Price |
$47.60
|
| Rate for Payer: Cigna Commercial |
$79.02
|
| Rate for Payer: First Health Commercial |
$90.45
|
| Rate for Payer: Humana Commercial |
$80.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.78
|
| Rate for Payer: Ohio Health Group HMO |
$71.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.52
|
| Rate for Payer: PHCS Commercial |
$91.40
|
| Rate for Payer: United Healthcare All Payer |
$83.78
|
|
|
D5%-0.2% Sod Chlor 1000mL
|
Facility
|
OP
|
$95.21
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004489
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$91.40 |
| Rate for Payer: Aetna Commercial |
$73.31
|
| Rate for Payer: Anthem Medicaid |
$32.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.26
|
| Rate for Payer: Cash Price |
$47.60
|
| Rate for Payer: Cigna Commercial |
$79.02
|
| Rate for Payer: First Health Commercial |
$90.45
|
| Rate for Payer: Humana Commercial |
$80.93
|
| Rate for Payer: Humana KY Medicaid |
$32.74
|
| Rate for Payer: Kentucky WC Medicaid |
$33.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.78
|
| Rate for Payer: Ohio Health Group HMO |
$71.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.52
|
| Rate for Payer: PHCS Commercial |
$91.40
|
| Rate for Payer: United Healthcare All Payer |
$83.78
|
|
|
DABIGATRAN 75MG CAPSULE
|
Facility
|
OP
|
$11.31
|
|
|
Service Code
|
NDC 597035509
|
| Hospital Charge Code |
25000510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$10.86 |
| Rate for Payer: Aetna Commercial |
$8.71
|
| Rate for Payer: Anthem Medicaid |
$3.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.82
|
| Rate for Payer: Cash Price |
$5.66
|
| Rate for Payer: Cigna Commercial |
$9.39
|
| Rate for Payer: First Health Commercial |
$10.74
|
| Rate for Payer: Humana Commercial |
$9.61
|
| Rate for Payer: Humana KY Medicaid |
$3.89
|
| Rate for Payer: Kentucky WC Medicaid |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.95
|
| Rate for Payer: Ohio Health Group HMO |
$8.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$10.86
|
| Rate for Payer: United Healthcare All Payer |
$9.95
|
|
|
DABIGATRAN 75MG CAPSULE
|
Facility
|
IP
|
$11.31
|
|
|
Service Code
|
NDC 597035509
|
| Hospital Charge Code |
25000510
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$10.86 |
| Rate for Payer: Aetna Commercial |
$8.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.82
|
| Rate for Payer: Cash Price |
$5.66
|
| Rate for Payer: Cigna Commercial |
$9.39
|
| Rate for Payer: First Health Commercial |
$10.74
|
| Rate for Payer: Humana Commercial |
$9.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.95
|
| Rate for Payer: Ohio Health Group HMO |
$8.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$10.86
|
| Rate for Payer: United Healthcare All Payer |
$9.95
|
|
|
DACARBAZINE 100MG
|
Facility
|
OP
|
$65.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
25002596
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$50.36
|
| Rate for Payer: Anthem Medicaid |
$22.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.01
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: First Health Commercial |
$62.13
|
| Rate for Payer: Humana Commercial |
$55.59
|
| Rate for Payer: Humana KY Medicaid |
$22.49
|
| Rate for Payer: Kentucky WC Medicaid |
$22.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.55
|
| Rate for Payer: Ohio Health Group HMO |
$49.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.27
|
| Rate for Payer: PHCS Commercial |
$62.78
|
| Rate for Payer: United Healthcare All Payer |
$57.55
|
|
|
DACARBAZINE 100MG
|
Facility
|
IP
|
$65.40
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
25002596
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.50 |
| Max. Negotiated Rate |
$62.78 |
| Rate for Payer: Aetna Commercial |
$50.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.01
|
| Rate for Payer: Cash Price |
$32.70
|
| Rate for Payer: Cigna Commercial |
$54.28
|
| Rate for Payer: First Health Commercial |
$62.13
|
| Rate for Payer: Humana Commercial |
$55.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.55
|
| Rate for Payer: Ohio Health Group HMO |
$49.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.27
|
| Rate for Payer: PHCS Commercial |
$62.78
|
| Rate for Payer: United Healthcare All Payer |
$57.55
|
|
|
DACARBAZINE 100MG VIAL
|
Facility
|
IP
|
$67.53
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
25002595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$64.83 |
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.67
|
| Rate for Payer: Cash Price |
$33.76
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: First Health Commercial |
$64.15
|
| Rate for Payer: Humana Commercial |
$57.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.43
|
| Rate for Payer: Ohio Health Group HMO |
$50.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.93
|
| Rate for Payer: PHCS Commercial |
$64.83
|
| Rate for Payer: United Healthcare All Payer |
$59.43
|
|
|
DACARBAZINE 100MG VIAL
|
Facility
|
OP
|
$67.53
|
|
|
Service Code
|
HCPCS J9130
|
| Hospital Charge Code |
25002595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$64.83 |
| Rate for Payer: Aetna Commercial |
$52.00
|
| Rate for Payer: Anthem Medicaid |
$23.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.67
|
| Rate for Payer: Cash Price |
$33.76
|
| Rate for Payer: Cigna Commercial |
$56.05
|
| Rate for Payer: First Health Commercial |
$64.15
|
| Rate for Payer: Humana Commercial |
$57.40
|
| Rate for Payer: Humana KY Medicaid |
$23.22
|
| Rate for Payer: Kentucky WC Medicaid |
$23.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.43
|
| Rate for Payer: Ohio Health Group HMO |
$50.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.93
|
| Rate for Payer: PHCS Commercial |
$64.83
|
| Rate for Payer: United Healthcare All Payer |
$59.43
|
|
|
DACOGEN 1MG/0.2ML(50MG/10ML VL
|
Facility
|
OP
|
$545.00
|
|
|
Service Code
|
HCPCS J0894
|
| Hospital Charge Code |
25002000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.85 |
| Max. Negotiated Rate |
$523.20 |
| Rate for Payer: Aetna Commercial |
$419.65
|
| Rate for Payer: Anthem Medicaid |
$187.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.10
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$452.35
|
| Rate for Payer: First Health Commercial |
$517.75
|
| Rate for Payer: Humana Commercial |
$463.25
|
| Rate for Payer: Humana KY Medicaid |
$187.43
|
| Rate for Payer: Kentucky WC Medicaid |
$189.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$191.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$479.60
|
| Rate for Payer: Ohio Health Group HMO |
$408.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.95
|
| Rate for Payer: PHCS Commercial |
$523.20
|
| Rate for Payer: United Healthcare All Payer |
$479.60
|
|
|
DACOGEN 1MG/0.2ML(50MG/10ML VL
|
Facility
|
IP
|
$545.00
|
|
|
Service Code
|
HCPCS J0894
|
| Hospital Charge Code |
25002000
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.85 |
| Max. Negotiated Rate |
$523.20 |
| Rate for Payer: Aetna Commercial |
$419.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.10
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$452.35
|
| Rate for Payer: First Health Commercial |
$517.75
|
| Rate for Payer: Humana Commercial |
$463.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$479.60
|
| Rate for Payer: Ohio Health Group HMO |
$408.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.95
|
| Rate for Payer: PHCS Commercial |
$523.20
|
| Rate for Payer: United Healthcare All Payer |
$479.60
|
|
|
DACRIOSE IRRIG SOLUTION 4 4OZ
|
Facility
|
IP
|
$3.17
|
|
|
Service Code
|
NDC 10119000252
|
| Hospital Charge Code |
25002979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Humana Commercial |
$2.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.79
|
| Rate for Payer: Ohio Health Group HMO |
$2.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.98
|
| Rate for Payer: PHCS Commercial |
$3.04
|
| Rate for Payer: United Healthcare All Payer |
$2.79
|
| Rate for Payer: Aetna Commercial |
$2.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.47
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna Commercial |
$2.63
|
| Rate for Payer: First Health Commercial |
$3.01
|
|
|
DACRIOSE IRRIG SOLUTION 4 4OZ
|
Facility
|
OP
|
$3.17
|
|
|
Service Code
|
NDC 10119000252
|
| Hospital Charge Code |
25002979
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$3.04 |
| Rate for Payer: Aetna Commercial |
$2.44
|
| Rate for Payer: Anthem Medicaid |
$1.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.47
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna Commercial |
$2.63
|
| Rate for Payer: First Health Commercial |
$3.01
|
| Rate for Payer: Humana Commercial |
$2.69
|
| Rate for Payer: Humana KY Medicaid |
$1.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.79
|
| Rate for Payer: Ohio Health Group HMO |
$2.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.98
|
| Rate for Payer: PHCS Commercial |
$3.04
|
| Rate for Payer: United Healthcare All Payer |
$2.79
|
|
|
DAILY POWER DEFENSE 50 ML GBL
|
Professional
|
Both
|
$150.00
|
|
| Hospital Charge Code |
22200144
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
|
|
DAKINS 1/2 STR [0.25%] S 480ML
|
Facility
|
OP
|
$1.31
|
|
|
Service Code
|
NDC 39328006325
|
| Hospital Charge Code |
25002981
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.01
|
| Rate for Payer: Anthem Medicaid |
$0.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.02
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna Commercial |
$1.09
|
| Rate for Payer: First Health Commercial |
$1.24
|
| Rate for Payer: Humana Commercial |
$1.11
|
| Rate for Payer: Humana KY Medicaid |
$0.45
|
| Rate for Payer: Kentucky WC Medicaid |
$0.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.15
|
| Rate for Payer: Ohio Health Group HMO |
$0.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.41
|
| Rate for Payer: PHCS Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Payer |
$1.15
|
|
|
DAKINS 1/2 STR [0.25%] S 480ML
|
Facility
|
IP
|
$1.31
|
|
|
Service Code
|
NDC 39328006325
|
| Hospital Charge Code |
25002981
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna Commercial |
$1.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.02
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna Commercial |
$1.09
|
| Rate for Payer: First Health Commercial |
$1.24
|
| Rate for Payer: Humana Commercial |
$1.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.15
|
| Rate for Payer: Ohio Health Group HMO |
$0.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.41
|
| Rate for Payer: PHCS Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Payer |
$1.15
|
|
|
DALIRESP 500MCG TABLET
|
Facility
|
IP
|
$5.07
|
|
|
Service Code
|
NDC 68382096906
|
| Hospital Charge Code |
25000511
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.87 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.95
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.21
|
| Rate for Payer: First Health Commercial |
$4.82
|
| Rate for Payer: Humana Commercial |
$4.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.46
|
| Rate for Payer: Ohio Health Group HMO |
$3.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.87
|
| Rate for Payer: United Healthcare All Payer |
$4.46
|
|
